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- Sep 9, 2004
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This will be my last post for quite awhile. I fear the coming changes due to the Health Care Bill will so fundamental to Pathology as to rival the very introduction of Medicare in 1965.
I still have no doubt that later in this decade or early in the next, Medicare and Medicaid itself will fall apart and the establishment of true multi-tiered health care system will unfortunately occur (Mayo Clinic has already dropped Medicare and Medicaid from its primary care mission, the remainder will follow mid decade I will predict). The middle class will be titanic losers in this process. The rich will retreat to smaller, exclusive medical arrangement with access to the full range of specialists on demand.
As I have had a decent university business education in my trials as a practice owner, I have a few assessments about what these changes will bring.
The big "Seachanges" to Pathology can be encapsulated in four points:
1.) the implementation of value-based purchasing
2.) the massive expansion of Medicaid rolls
3.) the massive reduction of Medicare spending
4.) the implementation of bundled Medicare payments
Any 4 of these are fairly calamitous individually for Pathology. All four of these simultaneously is literally the riding out of the 4 Horsemen.
To prevent a host of posts from idiot med students about how the poor and starving need medical care, I will reveal my own practice has never sent a single patient bill to collections. Ever. That means what people without insurance can pay I accept as payment be it 80% of the bill or 10% of the bill.
Do I feel they should pay nothing? No, of course not. That demeans me and you and our whole profession with a history dating back centuries.
I dont want to spend pages of text to go through the 4 points above and explain how they squeeze Pathology, I will leave it to you the readers to research the effects on your own.
I will explain how this will dramatically alter the current landscape:
~Consultations, now provided a separate CPT code that will essentially no longer exist, will evaporate. I predict sometime after the expansion of the bundled payment pilot in 2013 and its eventual adoption by private insurance, anyone who has a business model based on getting consults from other pathologists will have the lights turned out quite rapidly. This will actually be reinforced by the implementation of value-based purchasing analysis (which is set to begin sooner than 2013 I believe). Big losers: academic centers
~Molecular testing will undergo a massive contraction. Value-based purchasing and bundled payments will cause the near extinction of send out/esoteric testing. Cases for molecular analysis will be tightly limited to only those cases where there is a known treatment difference not prognostic one. The pathologist will become out of neccessity a tight filter for any expense not directly containable by the entity receiving the bundled payment. This will cause a seismic shift in the current independant laboratory world with such players as Quest Diagnostics etc. Big losers: reference labs
~Private practice pathologists who are practice owners with their own technical operation outside the hospital will face crisis. There are many large practices with free standing histology and immunohistochem businesses they rely on for a majority of their income. I do not feel these will survive the coming changes, either massive contraction or outright surrendering of the technical component to the entity/hospital getting the bundled payment. Big losers: private pathologists with histology labs
~Private practice pathologists in states where the corporate practice of medicine is illegal, such as California will face crisis. I do not believe private practice as it is now will exist by mid decade. Pathologists will become sub-contractors with a fixed reimbursement with which to pay expenses and their own salary. Basically, Pathologists will be left to negotiate their lump payment (no longer based on work as fee for service will die off) with hospitals. This is vastly worse than the NHS Brit model where doctors are paid government salaries BUT get government benefits, paid vacation and pensions. Big losers: private practice pathologists
~On the plus side, Pathology practices will no longer be able to charge any sort of buy in because their practice will simply have no resell value. This will definitely benefit younger, newer trainees. Winners: newly trained pathologists entering the workforce
~In order to maintain a level payment if at all possible, I expect the cases/pathologist to go astronomically high. This is very bad for job market in general as groups which have retirements will just contract and contract, working harder for the same chunk of their bundled payment. I would expect the mid to end decade to be one of the worst job markets for pathologists in history Losers: newly trained pathologists
~County facilities with massive medicaid populations will see a service explosion with the bill sent to state governors. This is very very bad unless you live in Texas (one of the few states with surplus). In California this is akin to the 2012 Apocalypse. I expect work volumes to literally go stratospheric and pay to go down by 50%+ or more. I expect newer hires to be excluded from cushy pension plans or special retirement benefits to keep down on cost. This will be a titanic battle with politicians, unions and doctors recreating Clash of the Titans in every major US city. County/public paid pathologists
~Relatively unaffected will be military physicians, physicians in VA hospitals, pathologists doing non-clinical work such as basic science research, forensics and government analysis. I do definitely expect academic salaries to be pushed down by the overall reduction in the comp analysis as well as the above issues. Perhaps more and more jr. staff being in the sub-100k/yr level.
Personally I would stay far away from niche areas like molecular testing. I would be incredibly careful about ANY debt you incur from education, training or whatever. Excessive education debt will be the millstone that destroys you and your family. Watch your debt paymentotential income ratio CAREFULLY.
As such do NOT overtrain, 1 fellowship is more than enough now.
I would favor broad training in AP/CP and not focused paths like AP/NP or AP/Dermpath. I would definitely favor AP/CP with no fellowship or AP+some soon to be worthless ABP certificate. Tommorrow's pathologist will need to sign out everything be it neuro, skin or bone marrow AND manage the lab.
Good luck and Godspeed to your destination
LADOC out.
I still have no doubt that later in this decade or early in the next, Medicare and Medicaid itself will fall apart and the establishment of true multi-tiered health care system will unfortunately occur (Mayo Clinic has already dropped Medicare and Medicaid from its primary care mission, the remainder will follow mid decade I will predict). The middle class will be titanic losers in this process. The rich will retreat to smaller, exclusive medical arrangement with access to the full range of specialists on demand.
As I have had a decent university business education in my trials as a practice owner, I have a few assessments about what these changes will bring.
The big "Seachanges" to Pathology can be encapsulated in four points:
1.) the implementation of value-based purchasing
2.) the massive expansion of Medicaid rolls
3.) the massive reduction of Medicare spending
4.) the implementation of bundled Medicare payments
Any 4 of these are fairly calamitous individually for Pathology. All four of these simultaneously is literally the riding out of the 4 Horsemen.
To prevent a host of posts from idiot med students about how the poor and starving need medical care, I will reveal my own practice has never sent a single patient bill to collections. Ever. That means what people without insurance can pay I accept as payment be it 80% of the bill or 10% of the bill.
Do I feel they should pay nothing? No, of course not. That demeans me and you and our whole profession with a history dating back centuries.
I dont want to spend pages of text to go through the 4 points above and explain how they squeeze Pathology, I will leave it to you the readers to research the effects on your own.
I will explain how this will dramatically alter the current landscape:
~Consultations, now provided a separate CPT code that will essentially no longer exist, will evaporate. I predict sometime after the expansion of the bundled payment pilot in 2013 and its eventual adoption by private insurance, anyone who has a business model based on getting consults from other pathologists will have the lights turned out quite rapidly. This will actually be reinforced by the implementation of value-based purchasing analysis (which is set to begin sooner than 2013 I believe). Big losers: academic centers
~Molecular testing will undergo a massive contraction. Value-based purchasing and bundled payments will cause the near extinction of send out/esoteric testing. Cases for molecular analysis will be tightly limited to only those cases where there is a known treatment difference not prognostic one. The pathologist will become out of neccessity a tight filter for any expense not directly containable by the entity receiving the bundled payment. This will cause a seismic shift in the current independant laboratory world with such players as Quest Diagnostics etc. Big losers: reference labs
~Private practice pathologists who are practice owners with their own technical operation outside the hospital will face crisis. There are many large practices with free standing histology and immunohistochem businesses they rely on for a majority of their income. I do not feel these will survive the coming changes, either massive contraction or outright surrendering of the technical component to the entity/hospital getting the bundled payment. Big losers: private pathologists with histology labs
~Private practice pathologists in states where the corporate practice of medicine is illegal, such as California will face crisis. I do not believe private practice as it is now will exist by mid decade. Pathologists will become sub-contractors with a fixed reimbursement with which to pay expenses and their own salary. Basically, Pathologists will be left to negotiate their lump payment (no longer based on work as fee for service will die off) with hospitals. This is vastly worse than the NHS Brit model where doctors are paid government salaries BUT get government benefits, paid vacation and pensions. Big losers: private practice pathologists
~On the plus side, Pathology practices will no longer be able to charge any sort of buy in because their practice will simply have no resell value. This will definitely benefit younger, newer trainees. Winners: newly trained pathologists entering the workforce
~In order to maintain a level payment if at all possible, I expect the cases/pathologist to go astronomically high. This is very bad for job market in general as groups which have retirements will just contract and contract, working harder for the same chunk of their bundled payment. I would expect the mid to end decade to be one of the worst job markets for pathologists in history Losers: newly trained pathologists
~County facilities with massive medicaid populations will see a service explosion with the bill sent to state governors. This is very very bad unless you live in Texas (one of the few states with surplus). In California this is akin to the 2012 Apocalypse. I expect work volumes to literally go stratospheric and pay to go down by 50%+ or more. I expect newer hires to be excluded from cushy pension plans or special retirement benefits to keep down on cost. This will be a titanic battle with politicians, unions and doctors recreating Clash of the Titans in every major US city. County/public paid pathologists
~Relatively unaffected will be military physicians, physicians in VA hospitals, pathologists doing non-clinical work such as basic science research, forensics and government analysis. I do definitely expect academic salaries to be pushed down by the overall reduction in the comp analysis as well as the above issues. Perhaps more and more jr. staff being in the sub-100k/yr level.
Personally I would stay far away from niche areas like molecular testing. I would be incredibly careful about ANY debt you incur from education, training or whatever. Excessive education debt will be the millstone that destroys you and your family. Watch your debt paymentotential income ratio CAREFULLY.
As such do NOT overtrain, 1 fellowship is more than enough now.
I would favor broad training in AP/CP and not focused paths like AP/NP or AP/Dermpath. I would definitely favor AP/CP with no fellowship or AP+some soon to be worthless ABP certificate. Tommorrow's pathologist will need to sign out everything be it neuro, skin or bone marrow AND manage the lab.
Good luck and Godspeed to your destination
LADOC out.